Association between burnout and empathy in medical residents

Background Burnout is a work-related syndrome that can affect physicians’ performance. Empathy is one of the clinical competencies in whose formation many factors play a role. Empathy and burnout are important topics of research in medical sciences, and both are related to the communication between the patient and the physician. This study investigated the relationship between occupational burnout and empathy among medical residents. Method This cross-sectional study was conducted on 297 medical residents in Ahvaz Jundishapur University of Medical Sciences from January to March 2021. The data collection tools were the Jefferson Scale of Empathy (JSE) and the Maslach Burnout Inventory (MBI). The reliability of the instruments was measured by calculating Cronbach’s alpha. Data were analyzed by SPSS-18, using the Pearson correlation test and linear regression models. Results The average age of the study population was 33.06 ±4.7 years, with more than half being females (57.6%) and married (51.9%). The residents’ mean scores of empathy and overall burnout were 102.87 out of 140 and 55.90 out of 132, respectively. The burnout scores showed an inverse correlation with the overall empathy scores (r = −0.123, P = 0.035), and the score of standing in the patient’s shoes (r = −0.165, P = 0.004). Linear regression test was used to detect which dimension of empathy was a better predictor for the reduction of burnout scores. Results showed that the best predictor was standing in the patient’s shoes (P = 0.014). Conclusion The findings showed a negative association between empathy and burnout among medical residents, which suggests the need for adjustment of the existing burnout management at the institutional level. Therefore, residents should be supported by managers to reduce burnout and improve their empathic behavior.

the reviewer's comment.Reviewer #2: Dear Author, Though it is an interesting research, there is always room for improvement.You may kindly consider the following points: 1) Thoroughly revise your manuscript and read your Abstract at two places in your article and make sure that both texts are the same and present in the main article as well.Try to improve your wording.The abstract was reviewed and revised.
2)Give further strength to your rationale/purpose of study.The rationale and purpose of the study were reviewed and completed.
3)In methods, too much detail is given under MEASURES section.Try to add your own performed METHODS rather than giving a literature review.Consider renaming your study design.Mention type of regression used.Exclusion criteria has some notincluded variables which may be deleted.If it is a census then there is no need to use the word SAPMLE or sampling technique.In the method section, corrections were made according to the reviewer's comment, and the manuscript was corrected based on the reviewer's comments.4) Reconsider your tables and make it more comprehensible and in standard formats especially table 1 and table 4. Table 3 can be adjusted within table 4. Kindly get guidance from other published researches how to report regression analysis.The tables were revised and Table 3 was merged into Table 4. 5) Rewrite a short but strong conclusion keeping in view your study objective and results.The conclusion was reviewed and revised in the abstract and in the final paragraph of the manuscript.This statement is required for submission and will appear in the published article if the submission is accepted.Please make sure it is accurate.
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This study was reviewed and approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences, and its code of ethics was issued (Ethic Code: IR.AJUMS.REC.1399.420).
The target group in this study were teaching assistants working in university teaching hospitals who participated in the study voluntarily and completed the questionnaires.
By being present at the place and explaining the objectives of the study and obtaining the satisfaction and participation of the participants, the researcher provided the questionnaires to them to complete and deliver.
According to the ethical statement, participation in the study was completely voluntary and participants were allowed to withdraw from the study at any time if they did not wish to continue cooperation.

Introduction
Medicine is a stressful profession.It is replete with stresses that result from inconsistent and contradictory processes that affect satisfaction and occupational burnout by reducing physical and mental health and occupational involvement.Burnout is a work-related psychological problem that causes emotional problems, reduced personal success, and depersonalization [1].Occupational burnout is one of the main problems in the quality of life of physicians and health care staff.High levels of burnout in doctors are a threat not only to the doctors themselves but also to their patients and the organizations they work for [2].Burnout is a multidimensional work-related syndrome that is associated with emotional exhaustion, depersonalization, and diminution of personal accomplishment [3].
Physicians are exposed to heavy workloads, stressful work environments, and high job pressure.These working conditions lead to various types of psychological problems such as anxiety, depression, and workplace burnout in these professionals.These psychological problems have a negative effect on the doctors' quality of life and their satisfaction, which will in turn affect the quality of care they provide to patients [4].Burnout has become a pervasive problem among medical professionals because can be highly sensitive to levels of empathy [5].
One of the factors related to burnout is empathy.Research has shown that physician empathy is an essential element in health care, which has a great impact on patient satisfaction and adherence to treatment [6].Empathy is the emotional and cognitive ability to understand the mental states, feelings, thoughts, and motives of others and to respond appropriately to them.Empathy is one of the characteristics of interpersonal behavior that is necessary for effective communication.People with high empathy have more prosocial behaviors while those having low empathy are characterized by more antisocial behaviors.Empathy is an essential element in the physicianpatient relationship and affects patient satisfaction and appropriate clinical outcomes [7].
A number of studies have addressed the relationship between empathy and burnout [3,5,8].Ferreira et al., for example, investigated the relationship between empathy and burnout among medical residents and specialists and found that the level of burnout increases with a decrease in empathy, and the aforementioned variable plays a significant role in predicting burnout [6].Kharidar Atiq also drew the conclusion that there is a negative and significant relationship between empathy and job burnout among nurses [8].In another research conducted by Yue on medical staff in a hospital in China, a negative relationship was found between empathy and job burnout [7].According to a systematic review by Wilkinson, the majority of the reviewed studies reported a negative relationship between empathy and job burnout [3].Of course, the results of some studies have reported a positive relationship between empathy and burnout [2,9], which needs further investigation.
Medical residents experience a great deal of stress during their training, and this stress eventually decreases their job satisfaction and increases burnout, imposing a large negative impact on the mental health of the residents and the quality of patient care [10,11].A number of studies have shown that empathy is one of the factors that protect the mental health of medical staff against burnout [12,13].In Iran, the relationship between empathy and burnout has already been investigated in nurses [8].However, to the best of our knowledge and review of literature, no previous study has investigated the relationship between empathy and burnout among medical residents in Iran.This study was conducted in order to fulfill this gap in literature.Therefore, given the particular importance of burnout in the mental health and empathic behavior of residents, this study aims to explore the relationship between burnout and empathy among Iranian medical residents.The findings of this study may serve as a foundation for designing mental health interventions, especially those aimed at improving resident empathy.

Method Study design and participants
This was a cross-sectional investigating the relationship between burnout and empathy in a population of medical residents in Iran.All medical residents studying at Ahvaz Jundishapur University of Medical Sciences (AJUMS) were recruited in this study (n = 472).Of all these residents, 297 completed the questionnaire (the response rate was 63.1 %.).The inclusion criteria were willingness to participate in the study and completing the questionnaire.The exclusion criteria were unwillingness to participate in the study, and inadequate completion of the questionnaires.Data were collected between January 1 st and March 30 th , 2021.The data were collected in a hospital following relevant guidelines and using a paper-based process.As far as the paper-based method was concerned, a research assistant handed the participants an information sheet delineating the study's rationale and the allotted time to complete the survey.They had 10 minutes to decide whether they were willing to collaborate in the study or not.If they were willing to participate, the research assistant handed them the questionnaires.Participation in the study was voluntary, and there was no compensation for completing the questionnaire.Adhering to the policy of strict confidentiality, the signatures of the participants were not required, and all the participants retained the right to withdraw from the research at any time without giving any reason.

Instruments
All medical residents provided socio-demographic information and completed validated questionnaires on burnout and empathy [9].
Burnout was measured using the Persian version of Maslach Burnout Inventory (MBI).This instrument is a scale composed of 22 items that are scored based on a 7-point Likert scale ranging from 0 (never) to 6 (everyday).The total score of the tool is obtained through the sum of the scores of all items, so the range of the total score is between 0 and 132, with higher scores indicating greater burnout.The scale measures three dimensions: emotional exhaustion, depersonalization, and lack of personal accomplishment [14].The validity and reliability of this scale have been evaluated in many studies, and it has been shown that this tool and its dimensions have sufficient validity [15][16][17].The validity and reliability of this questionnaire have also been evaluated and confirmed in Iran, and its reliability coefficient has been estimated at 0.751 using Cronbach's alpha method [18].In the present study, the reliability of the questionnaire was calculated by obtaining a Cronbach's alpha of 0.675.

Empathy was measured using the Persian version Jefferson Scale of Physician Empathy (JSPE)
The JSPE was developed and standardized by Hojat in 2002 [19].This instrument is a scale composed of 20 items that are scored based on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).The total score of the tool is obtained through the sum of the scores of all items, so the range of the total score is between 20 and 140, with higher scores representing greater empathy.This questionnaire has three dimensions: Perspective Taking, Compassionate Care, and Walking in Patient's Shoes.The validity and reliability of this questionnaire have been confirmed in numerous studies [19][20][21].In Iran, Shariat et al. reported a Cronbach's alpha coefficient of 0.88 for the Persian version of this questionnaire [21].In the present study, the reliability of JSPE was calculated obtaining a Cronbach's alpha of 0.766.

Ethical and confidentiality considerations
The study was approved by the Ethics Committee of the Ahvaz Jundishapur University of Medical Sciences (Ref.ID: IR.AJUMS.REC.1399.420).After obtaining the necessary permits for sampling, the researchers went to the teaching hospitals, and after explaining the objectives of the study to the residents and obtaining their consent to participate in the study, the mentioned questionnaires were given to them.Participation in the study was completely optional, the questionnaires were anonymous, and the residents were assured of the confidentiality of their information.

Statistical analysis
The normality of data distribution was checked using the Kolmogorov-Smirnov test which indicated normal distribution of data.The reliability of the MBI and JSPE was measured by calculating Cronbach's alpha.Data were analyzed using the Statistical Package for the Social Sciences (SPSS) (Version 18.0).We described the numerical data by mean and standard deviation (SD), and nominal data was described as raw counts (n) and percentages (%).The burnout and empathy scores of the residents were calculated.In order to investigate the relationship between burnout and the demographic variables, Pearson's correlation coefficient and linear regression model were used.P values < 0.05 were considered statistically significant.

Demographic characteristics
A total of 297 residents with a mean age of 33.06 ±4.7 years participated in the present study.More than half of the respondents were females (57.6%) and married (51.9%).The mean burnout score of the residents was 55.90±13.25 while their mean empathy score was 102.13±25.The mean scores of burnout and empathy along with their dimensions are displayed in Table 1.Table 2 shows the correlation coefficients between the residents' mean burnout and empathy scores and between dimensions of burnout and empathy.The results show that there is a significant negative relationship between burnout and empathy (r=-0.123;p=0.035).The correlation coefficients between burnout and empathy dimensions were also negative.However, this relationship was significant only in the sub-scale of "Walking in Patient's Shoes" (r=-0.165;p=0.004).The correlation coefficients of EE and DP dimensions of burnout with empathy and its dimensions were also negative.However, the relationship of PA dimensions of burnout with empathy and its dimensions was positive (Table 2).3.As the findings of this table show, empathy is a negative and significant predictor of burnout.

Linear regression was used to investigate the relationship between burnout and empathy and between their dimensions and to see to what extent and in what direction empathy and its dimensions predict burnout. The results of the linear regression equation are given in Table
According to Table 3, the results of linear regression analysis indicate that the explanatory variables (empathy dimensions) can significantly predict and explain changes in the dependent variable (residents' burnout).In other words, the model is meaningful, and among the three dimensions of empathy (i.e., Perspective Taking, Compassionate Care, and Walking in Patient's Shoes) the most determining component is walking in Patient's Shoes.This sub-scale is a negative and significant predictor of job burnout and explains a total of 2.3% of the variance of burnout.
The results also showed that among the three burnout dimensions, emotional exhaustion has the least relationship with empathy dimensions.Also, none of the dimensions of empathy could act as a predictive factor to predict emotional exhaustion in residents.However, the two dimensions of DP and PA could be predicted by the empathy dimensions.
The regression model showed that the empathy dimensions could predict the DP sub-scale of burnout and explain 19.5% of the burnout variance.However, as far as the PA subscale is concerned, empathy dimensions could predict burnout and positively explain 12% of the variance of burnout (Table 3).

Discussion
This study investigated the relationship between empathy and burnout in medical residents.According to our results, the mean empathy score of the residents was 102.78 ± 12.73, with the lowest and highest possible scores of empathy being 20 and 140, respectively.These results indicate that the studied residents' level of empathy is above average, which is in line with the findings of Shariat [21] and Aziz [22], who reported an average level of empathy among the residents in their study.However, in other studies, the level of residents' empathy level has been reported to be lower or higher than average [12,23,24].The inconsistency of these results can be attributed to differences in education and health care systems, and to cultural differences that shape patients' expectations of an "ideal physician." In this study, the mean burnout score of the studied residents was 55.90±13.25,with the minimum and maximum scores of burnout ranging between 0 and 132.These results indicate that the level of burnout among the residents is lower than average.The literature suggests that many physicians are at risk of burnout or are currently suffering from it.In line with the results of the present study, a systematic review reported the level of burnout in the medical staff to be at an average level [25].Passos in Brazil reported a high level of burnout among medical residents [26].In a similar study in Nigeria, a severe degree of burnout in residents was reported [27].Medical residents face stressful situations during their training, especially when they are in clinical settings.These include acute diseases, accidents, death, and night shifts, which require planning and changes in the curriculum to improve their quality of life and reduce burnout.
In the present study, a negative correlation was found between the empathy and burnout scores.Specifically, an increase in the empathy score led to a decrease in the burnout score.These results are similar to previous reports in other populations [6,12,[28][29][30], which means that when physicians are at a high level of burnout, their relationship with their patients seems to worsen.The empathy between the patient and the physicians promotes mutual trust and thus the effectiveness of the treatment.In a study investigating the role of empathy in burnout, Wagman et al. reported that higher levels of empathy are associated with lower levels of burnout [29].They maintained that given the fact that low empathy can make people more vulnerable to burnout and that strengthening empathy skills can reduce or prevent burnout, it is better to include empathy in medical education programs.
The findings of this study are consistent with those of Yu [7], Khalid [28], and Lee [30] who reported a negative and significant relationship between empathy and burnout.In a systematic review, Wickenson et al. reported a negative relationship between empathy scores and burnout in most studies conducted on healthcare staff [3].Wang et al. also reported that empathy has a positive relationship with job satisfaction but a negative association with burnout [4].To explain this finding, it can be argued that empathy is essential for successful interpersonal functioning, which provides the basis for improving proper relationships with others.If interpersonal relationships and empathy among employees are strengthened, their resilience against difficult situations will automatically increase, and their burnout will experience a downward trend.Examining the relationship between burnout and empathy, Zenasni et al. noted that empathy protects doctors from burnout [31].According to their study, empathy requires awareness of negative emotions and obliges the doctor to understand patients' mental and psychological conditions through positive interactions.These interactions are resources to deal with stress and burnout at the workplace.Therefore, helping physicians practice more empathy can help protect them from burnout [32].
Despite the compelling evidence indicating a negative relationship between empathy and burnout, there are also studies that have reported a positive correlation between these two variables [3,9].This hypothesis is somewhat consistent with Maslach and Jackson's theory according to which empathetic employees are more likely to experience burnout [3].Considering burnout as a crosscultural construct, the available evidence emphasizes that the language in which the questionnaire is written may affect the way participants respond to its questions, which will lead to different results.Certainly, further research will shed more light on this topic.
In a systematic review of studies conducted on the relationship between empathy and burnout, Delgado et al. reported that burnout is somewhat associated with depersonalization.In fact, when human aspects of social interactions are reduced, this is likely to lead to a significant reduction in empathy.Hence, burnout is fatal for both the doctor and the patient.Exhausted doctors are less likely to have the ability to stand in the patient's shoes and listen actively.Instead, they prefer to protect themselves by distancing themselves from patients and depersonalizing them.Delgado et al. maintain that the higher the burnout level of physicians, the lower their clinical empathy [13].Investigating and understanding the complex links between empathy and burnout can help healthcare professionals as well as educational institutions to reduce the risk of burnout.
Our analysis of the relationship between burnout and empathy subscales showed that out of the three empathy subscales, only "Walking in Patient's Shoes" had a significant relationship with burnout, and this subscale can act as a predictive factor and predict burnout in residents.Based on this, residents who had less empathy were associated with higher levels of burnout.In other words, the ability to "walk in the patient's shoes" provides a protective effect for the residents against burnout.Rodríguez-Nogueira et al. suggest that burnout plays a challenging role in clinical empathy and that burnout can affect empathy levels by creating job dissatisfaction [33].
The findings of this study show the discrete importance of different empathy subscales because their impact on burnout subscales is different.Among the three burnout subscales, emotional exhaustion showed the lowest correlation with empathy and its subscales.Examining the relationship between burnout subscales and empathy subscales showed that there is a significant negative relationship between empathy subscales and emotional exhaustion.However, none of the subscales of empathy has the power to predict emotional exhaustion in the residents.There was a negative and significant relationship between the subscale of depersonalization and empathy and its subscales.Also, the two subscales of "Perspective Taking" and "Walking in Patient's Shoes" could predict the depersonalization subscale in the residents.The results of our regression analysis revealed that these two variables together could predict burnout in a negative direction with a determination coefficient of 19.5% of the variance.Regarding the relationship between the subscale of "lack of personal accomplishment" with empathy and its subscales, it was observed that there is a positive relationship between these variables and that the subscales of "Perspective Taking" and "Compassionate care" could predict the subscale of "lack of personal accomplishment" and explain a total of 12% of the variance.In a systematic review, the relationship of different components of empathy with each component of burnout in doctors was investigated [13].The results showed that the subscales of emotional exhaustion and depersonalization had a negative relationship with the subscales of perspective-taking, compassionate care, and walking in the patient's shoes.There was also a positive relationship between the subscale of "lack of personal accomplishment" and the subscales of empathy, and high levels of "lack of personal accomplishment" were associated with high levels of "perspectivetaking", "compassionate care", and "walking in the patient's shoes", which is consistent with the findings of our study.
Residents should be aware that dealing with patients' pain and suffering on a regular basis puts their emotional health at risk, and that experiencing strong emotions and feelings may affect their personal life.Therefore, having an understanding of burnout and dealing with it as a reality is essential to a resident's career survival.Residents must learn how to protect themselves in this way.A previous study found that residents who had lower empathy scores also had a lower quality of life [34].Also, in another study, a significant relationship was found between the scores of quality of life and burnout [35].In a content analysis study, Ahmadian et al. reported that burnout plays a challenging role in clinical empathy [36].They showed that lack of coping strategies may create a high level of stress and burnout and that extracurricular educational activities, which are considered as coping mechanisms, can have a good effect on mental and physical health and reduce stress and burnout.In order to reduce job burnout and increase the quality of life, planning for extracurricular activities should be done in order to increase coping mechanisms against stress and burnout in students.Managers of residency curricula should be sensitive to the need for the inclusion of training programs for teaching empathic strategies and emotional management for the professional development of medical residents.This will improve the mental health of residents and enhance the quality of medical services by reducing the rate of burnout.This research had a number of limitations.The main limitation was that this study was conducted only in one university, which limits the generalizability of the results.Another limitation is that data collection was done through convenience sampling, a method that can lead to biases in data collection and sampling.Therefore, caution should be exercised when interpreting the results, paying attention to the fact that the participants in the study were not selected randomly and were not from several universities.Additionally, we did not study other factors that may influence levels of empathy or burnout.These include personality traits, prior psychiatric disorders, or a history of using medication.Further studies should be conducted to determine other factors influencing empathic capacity during the physician's career.

Conclusion
The findings of this study showed a negative association between empathy and burnout among medical residents, which suggests the need for adjustment of the existing burnout management practices at the institutional level.Of all dimensions of empathy, walking in the patient's shoes had the most important association with reduced burnout scores and was also a predicting variable for burnout.Medical educators must take these findings into account when planning innovative strategies to promote empathy among medical residents.Therefore, residents should be supported by managers to reduce burnout and improve empathic behavior.

Introduction
Medicine is a stressful profession.It is replete with stresses that result from inconsistent and contradictory processes that affect satisfaction and occupational burnout by reducing physical and mental health and occupational involvement.Burnout is a work-related psychological problem that causes emotional problems, reduced personal success, and depersonalization [1].Occupational burnout is one of the main problems in the quality of life of physicians doctors and health care staff.High levels of burnout in doctors are a threat not only to the doctors themselves, as well as but also to their patients and the organizations they work for [2].Burnout is a multidimensional work-related syndrome that is associated with emotional exhaustion, depersonalization, and diminution of personal accomplishment [3].
Physicians are exposed to heavy workloads, stressful work environments, and high job pressure.These working conditions lead to various types of psychological problems such as anxiety, depression, and job workplace burnout in these professionals.These psychological problems have a negative effect on the doctors' quality of life and their satisfaction of doctors' lives, which in turn will in turn affect the quality of care they provided to patients [4].Burnout has become a pervasive problem among medical professionals because burnout it can be highly sensitive to levels of empathy [5].
One of the factors related to burnout is empathy.Research has shown that physician empathy is an essential element in health care, which has a great impact on patient satisfaction and adherence to treatment [6].Empathy is the emotional and cognitive ability toof understanding the mental states, of feelings, thoughts, and motives of others and to responding appropriately to them.Empathy is one of the characteristics of interpersonal behavior that is necessary for effective communication.People with high empathy have more prosocial behaviors while those having low empathy are characterized by more antisocial behaviors.Empathy is an essential element in the physicianpatient relationship and affects patient satisfaction and appropriate clinical outcomes [7].
A number of sSeveral studies have been done onaddressed the relationship between empathy and job burnout [3,5,8].For example, Ferreira et al., for example, investigated the relationship between empathy and burnout in among medical residents and specialists and found that the level of burnout increases with a decrease in empathy, and the aforementioned variable plays a significant role in predicting burnout [6].In a research, Kharidar Atiq also came todrew the conclusion that there is a negative and significant relationship between empathy and job burnout of among nurses [8].In another research conducted by Yue on medical staff in a hospital in China, there was a negative relationship was found between empathy and job burnout [7].According to a systematic review by Wilkinson, the majority of the reviewed studies reported a negative relationship between empathy and job burnout [3].Of course, The the results of some studies have shown that there isreported a no or positive relationship between empathy and job burnout [2,9], which needs further investigation.
Medical residents experience a great deal of stress during their training, and this stress eventually causes a decrease in occupationdecreases their job satisfaction and an increases in burnout, imposing a large negative impact on the mental health of the residents and the quality of patient care [10,11].A number of studies have shown that empathy is one of the factors that protect the mental health of medical staff against burnout [12,13].In Iran, the relationship between empathy and burnout has already been investigated in nurses [8].However, to the best of our knowledge and based on our searchand review of literature, there were no previous studiesy concerninghas investigated the relationship between empathy and burnout among medical residents in Iran.This study was conducted in order to fulfill this research gap in literature.Therefore, given the particular importance of burnout in the mental health and empathic behavior of residents, this study aims to explore the relationship between burnout and empathy among Iranian medical residents.the relationship between these two variables has not been investigated in medical residents.Therefore, given the particular importance of empathy and its role in the mental health of residents, the present study aims to investigate the relationship between empathy and burnout and to determine the role of empathy in predicting the burnout of medical residents.The findings of this study may serve as a foundation for designing mental health interventions, especially those aimed at improving residents' empathy.

Study design and Pparticipants
This study was a cross-sectional design, to study the association ofinvestigating the relationship between burnout and empathy in a population of medical residents in Iran.All medical residents studying at Ahvaz Jundishapur University of Medical Sciences (AJUMS) were recruited in theis study (n = 472).Of themall these residents, 297 medical residents completed the questionnaire (the response rate was 63.1%63.1 %.).After approval from the corresponding ethics committees of the Ahvaz Jundishapur University of Medical Sciences=AJUMS (Ethic Code: IR.AJUMS.REC.1399.420),this correlational cross-sectional descriptive study was conducted on all medical residents attending the teaching hospital in AJUMS.All medical residents (n = 472) at AJUMS were recruited in the study.using the convenient sampling method.The inclusion criteria were to study in one of the medical residency courses in AJUMS and a willingness to participate in the study and completing the questionnaireresearch.The exclusion criteria were unwillingness to participate in the study, or failure to complete or and incomplete inadequate completion of the questionnaires.
Data were collected betweenfrom 1st January 1 st and2021 to 30th March 30 th , 2021.using a convenient sampling method.The data were collected in the givena hospital following relevant guidelines and by using a paper-based process.Concerning As far as the paper-based method was concerned, a research assistant handed them the participants an information sheet delineating the study's rationale and the allotted time to complete the survey.They had 10 minutes to consider decide whether they were willing to collaborate in the study or not.If they wished were willing to participate, the research assistant handed them the questionnaires.Participation in the study was voluntary, and there was no compensation for completing the questionnaire.Adhering to the policy of strict confidentiality, the signatures of the participants were not required, and all the participants retained the right to withdraw from the research at any time without giving any reason.

All of the medical residents provided socio-demographic information and completed validated questionnaires on burnout and empathy
The Jefferson Scale of Empathy (JSE) and The Maslach Burnout Inventory (MBI) were used to collect data.MBI was used to measure burnout [9].Burnout was measured using the Persian version of Maslach Burnout Inventory (MBI).This questionnaire was developed by Christian Maslach and Susan X. Jackson in 1981 with the aim of assessing the individual's experience of burnout.This instrumenttool is a scale composed of has 22 items that are scored based based on a 7seven-point Likert scale ranging from 0 (never) zero to 6 (every day)six.The total score of the tool is obtained through the sum of the scores of all items, so the range of the total scores is between 0 and 132, and awith higher scores means indicating greater burnout.The scale measures three dimensions:;MBI measures emotional exhaustion, depersonalization, and lack of personal accomplishment .The first sub-scale of this questionnaire Formatted: Superscript Formatted: Superscript is emotional exhaustion and it contains 9 items that measure people's feelings, interest, and attitude towards their job.The second sub-scale, depersonalization, includes 5 items that evaluate impersonal and emotionless responses of people towards colleagues and clients.The third subscale, lack of personal accomplishment, examines the individual's sense of sufficiency and success in their job in 8 items.By adding up the scores, the scores of each of the three subtests can be calculated.In this questionnaire, a higher score indicates a greater burnout experience [14].The validity and reliability of this scale have been evaluated in many studies, and it has been shown that this tool and its sub-scalesdimensions have sufficient validity .Ilic calculated the reliability coefficient of the burnout scale by obtaining a Cronbach's alpha of 0.869 for emotional exhaustion, 0.856 for depersonalization, 0.852 for lack of personal accomplishment, and 0.757 for the whole questionnaire [17].The validity and reliability of this questionnaire in Iran have also been evaluated checked and confirmed in Iran, and its reliability coefficient has been estimated at 0.751 using Cronbach's alpha method [18].In the present study, the reliability of the questionnaire was calculated by obtaining a Cronbach's alpha of 0.675.

Empathy was measured using the Persian version Jefferson Scale of Physician Empathy (JSPE)
The JSPE was developed and standardized by Hojat in 2002 [19].This instrument is a scale composed of 20 items that are scored based on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree).The total score of the tool is obtained through the sum of the scores of all items, so the range of the total scores is between 20 and 140, and awith higher scores meansrepresenting greater empathy.This questionnaire contains 20 items to which the respondent gives a score from one to seven, based on their level of agreement, with the number one indicating the least agreement and the number seven indicating the highest agreement.The minimum score is 20 and the maximum score is 140.A higher score represents greater empathy with the patient.This questionnaire has three sub-scalesdimensions: Perspective Taking with 10 questions (score range between 10 and 70), Compassionate Care with 8 questions (score range between 8 and 56), and Walking in Patient's Shoes with 2 questions (score range between 2 and 14).The validity and reliability of this questionnaire have been confirmed in numerous studies [19][20]21].Hojat et al. investigated and confirmed the validity and reliability of this tool [19].In Iran, Shariat et al. reported the a Cronbach's alpha coefficient of 0.88 for the Persian version of this questionnaire to be 0.88 and its test-retest reliability coefficient to be 0.94 [21].In the present study, the reliability of this questionnaireJSPE was calculated obtaining a Cronbach's alpha of 0.766.

Ethical and confidentiality aspectsconsiderations
The study was approved by the eEthics cCommittees of the Ahvaz Jundishapur University of Medical Sciences (Ethic CodeRef.ID: IR.AJUMS.REC.1399.420).After obtaining the necessary permits for sampling, the researchers went to the teaching hospitals; , and after explaining the objectives of the studyresearch to the residents and obtaining their consent to participate in the studyresearch, the mentioned questionnaires were given to them.Participation in the study was completely optional, the questionnaires were anonymous, and the residents were assured of the confidentiality of their information.

Statistical analysis
At first, Tthe normality of the data distribution was checked using the Kolmogorov-Smirnov test which indicated the normal distribution of data.The reliability of the MBI and JSPE was measured by calculating Cronbach's alpha.Data were analyzed using the Statistical Package for the Social Sciences (SPSS) (Version 18.0).We described the numerical data utilizing by mean and standard deviation (SD); ), and nominal data was described as raw counts (n) and percentages (%).The burnout and empathy scores of the residents were calculated.In order to investigate the relationship between burnout and the demographic variables, Pearson's correlation coefficient and linear regression model were used.P values < 0.05 were considered statistically significant.

Demographic characteristics
The medical residents who completed the questionnaire were 297 of the 472 total residents that were approached; the response rate was 63.1%.
A total of 297 residents with a mean age of 33.06 ±4.7 years participated in the present study.More than half of the respondents were females (57.6%), and married (51.9%).Of them, 67 (22.6%) in the first year, 31.3% in the second year, 22.9% in the third year, and 23.2% in the fourth year.Most of them were female (57.6%) and married (51.9%).Overall, their mean age was 33.06 ±4.7 years.The mean burnout score of the residents was 55.90±13.25 while their mean empathy score was 102.13±25.The mean scores of burnout and, and empathy and along with their dimensions their sub-scales areare displayedshown in Table 1.Table 2 shows the correlation coefficients between the residents' mean burnout and empathy scores of residents and the mean empathy scores andand between their sub-scalesdimensions of burnout and empathy.The results show that there is a significant negative relationship between burnout and empathy (r=-0.123;p=0.035).The correlation coefficients between burnout and empathy sub-scalesdimensions were also negative.However, this relationship was significant only in the sub-scale of "Walking in Patient's Shoes" (r=-0.165;p=0.004).The correlation coefficients of EE and DP sub-scalesdimensions of burnout with empathy and its sub-scalesdimensions were also negative.However, the relationship of PA dimensions sub-scale of burnout with empathy and its sub-scalesdimensions was positive (Table 2).Linear regression was used to investigate the relationship between burnout and empathy and its between their sub-scalesdimensions and to see to what extent and in what direction empathy and its sub-scalesdimensions predict burnout.The results of the linear regression equation are given in Table 3.As the findings of Table 3this table show, empathy is a negative and significant predictor of burnout.34, the results of linear regression analysis indicate that the explanatory variables (empathy sub-scalesdimensions) can significantly predict and explain changes in the dependent variable (residents' burnout).In other words, the model is meaningful, and among the three sub-scalesdimensions of empathy, (i.e., Perspective Taking, Compassionate Care, and Walking in Patient's Shoes), the most determining component is walking Walking in Patient's Shoes.This sub-scale is a negative and significant predictor of job burnout and explains a total of 2.3% of the variance of burnout.

Table 1. The residents' Mmean scores of burnout and empathy and along with their subscalesdimensions inamong medical residents
The results also showed that among the three burnout sub-scalesdimensions, emotional exhaustion has the least relationship with empathy sub-scalesdimensions. Also, none of the subscalesdimensions of empathy could act as a predictive factor to predict emotional exhaustion in residents.However, the two sub-scalesdimensions of DP and PA could be predicted by the empathy sub-scalesdimensions.
The regression model showed that the empathy sub-scalesdimensions could predict the DP subscale of burnout and explain 19.5% of the burnout variance.However, as far as the PA subscale is concerned, empathy sub-scalesdimensions could predict burnout and positively explain 12% of the variance of burnout (Table 43).

Discussion
This study investigated the relationship between empathy and burnout in medical residents.According to our results, the mean empathy score of the residents was 102.78 ± 12.73, which varies betweenwith the lowest and highest possible scores of empathy being 20 and 140, according to the empathy score rangerespectively.These results indicate that the studied residents' level of empathy is above average, which is in line with the findings of Shariat [21] and Aziz [22], who reported an average level of empathy of among the residents in their study.However, in other studies, the level of residents' empathy level has been reported to be lower or higher than average [12,23,24].The inconsistency of these results can be attributed to differences in education and health care systems, and to cultural differences that determine shape patients' expectations of an "ideal physician."

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In this study, the mean burnout score of the studied residents was 55.90±13.25,with the minimum and maximum scores of burnout ranging between 0 and 132.These results indicate that the level of burnout among the residents is lower than average.The literature suggests that many physicians are at risk of burnout or are currently suffering from it.In line with the results of the present study, a systematic review has reported the level of burnout in the medical staff to be at an average level [25].Passos in Brazil has reported a high level of burnout among medical residents [26].In a similar study in Nigeria, a severe level degree of burnout in residents has beenwas reported [27].Medical residents face stressful situations during their training, especially when they are in clinical settings.These include acute diseases, accidents, death, and night shifts, which require planning and changes in the curriculum to improve their quality of life and reduce burnout.
In the present study, a negative correlation was found between the empathy score and the burnout scores.Specifically, with an increase in the empathy score, led to a decrease in the burnout score decreased.These results are similar to previous reports in other populations [6,12,[28][29][30].], This which means that when physicians are at a high level of burnout, their relationship with their patients seems to become poorworsen.The empathy between the patient and the physicians increases promotes mutual trust and thus the effectiveness of the treatment.In a study investigating the role of empathy in burnout, Wagman et al. reported that higher levels of empathy are associated with lower levels of burnout [29].He They maintained stated that given the fact that low empathy can make people more vulnerable to burnout and that strengthening empathy skills can reduce or prevent burnout, it is better to include empathy in the program of medical education programs.
The findings of this study are consistent with those of Yu [7], Khalid [28], and Lee [30] who reported a negative and significant relationship between empathy and burnout.In a systematic review, Wickenson et al. reported a negative relationship between empathy scores and burnout in most of the studies conducted on healthcare staff [3].Wang et al. also reported that empathy has a positive relationship with job satisfaction and but a negative association with burnout [4].In To explaining this finding, it can be argued that empathy is essential for successful interpersonal functioning, which provides the basis for improving proper relationships with others.If interpersonal relationships and empathy among employees are strengthened, their resilience against difficult situations will automatically increase, and their burnout will experience a downward trend.Examining the relationship between burnout and empathy, Zenasni et al. noted that empathy protects doctors from burnout [31].According to that their study, empathy requires awareness of negative emotions and obliges the doctor to understand patients' mental and psychological conditions through positive interactions.These interactions are resources to deal with stress and burnout at the workplace.Therefore, helping physicians practice more empathy can helps protect them from burnout [32].
Despite the compelling evidence indicating a negative relationship between empathy and burnout, there are also studies that have reported a positive correlation between these two variables [3,9].This hypothesis is somewhat consistent with Maslach and Jackson's theory that according to which empathetic employees are more likely to experience burnout [3].Considering burnout as a crosscultural construct, the available evidence emphasizes that the language of in which the questionnaire is written may affect the way the participants responds to the its questions, which will leading to different results.Certainly, more future studiesfurther research will shed more light on this topic.In a systematic review of studies conducted on the relationship between empathy and burnout, Delgado et al. reported that burnout is somewhat associated with depersonalization.In fact, when human aspects of social interactions are reduced, this is likely to lead to a significant reduction in empathy.Hence, burnout is fatal for both the doctor and the patient.Exhausted doctors are less likely to have the ability to stand in the patient's shoes and listen actively.Instead, they prefer to protect themselves by distancing themselves from patients and depersonalizing them.Delgado et al. maintains that the higher the burnout level of physicians, the lower their clinical empathy [13].Investigating and understanding the complex links between empathy and burnout can help healthcare professionals as well as educational institutions to reduce the risk of burnout.
Our analysis of the relationship between burnout and empathy subscales showed that out of the three empathy subscales, only "Walking in Patient's Shoes" had a significant relationship with burnout, and this subscale can act as a predictive factor could and predict burnout in residents.Based on this, residents who had less empathy had were associated with higher levels of burnout.In other words, the ability to "walk in the patient's shoes" provides a protective effect for the residents against burnout.Rodríguez-Nogueira et al. suggest that burnout plays a challenging role in clinical empathy and that burnout by creating job dissatisfaction can affect empathy levels by creating job dissatisfaction [33].
The findings of this study show the discrete importance of different empathy subscales separately because their impact on burnout subscales is different.Among the three burnout subscales, emotional exhaustion showed the lowest correlation with empathy and its subscales.Examining the relationship between burnout subscales and empathy subscales showed that there is a significant negative relationship between empathy subscales and emotional exhaustion.However, none of the subscales of empathy as a predictive factor has the power to predict emotional exhaustion in the residents.There was a negative and significant relationship between the subscale of depersonalization and empathy and its subscales.Also, the two subscales of "Perspective Taking" and "Walking in Patient's Shoes" as predictive factors could predict the depersonalization subscale in the residents.The results of our regression analysis revealed that these two variables combined together could predict burnout in a negative direction with a determination coefficient of 19.5% of the variance.Regarding the relationship between the subscale of reduced personal success"lack of personal accomplishment" with empathy and its subscales, it was observed that there is a positive relationship between these variables and that the subscales of "Perspective Taking" and "Compassionate care" are able tocould predict the subscale of "lack of personal accomplishment"reduced personal success, and they explained a total of 12% of the variance.In a systematic review, the relationship between of different components of empathy and with each component of burnout in doctors was investigated [13].The results showed that there is a negative relationship between the subscales of emotional exhaustion and depersonalization had a negative relationship with the subscales of perspective-taking, compassionate care, and walking in the patient's shoes.There was also a positive relationship between the subscale of "lack of personal accomplishment"personal failure and the subscales of empathy, and high levels of reduced personal success"lack of personal accomplishment" were associated with high levels of "perspective-taking", "compassionate care", and "walking in the patient's shoes", which is consistent with the findings of our study.
Residents should be aware that dealing with patients' pain and suffering on a regular basis puts their emotional health at risk, and that experiencing strong emotions and feelings may affect their personal life.Therefore, having an understanding of burnout and dealing with it as a reality is essential to a resident's career survival.Residents must learn how to protect themselves in this way.A previous study found that residents who had lower empathy scores also had a lower quality of life [34].Also, in another study, a significant relationship was found between the scores of quality of life and burnout [35].Ahmadian et al. reported iIn a content analysis study, Ahmadian et al. reported that burnout plays a challenging role in clinical empathy [36].They showed that a lack of coping strategies may create a high level of stress and burnout and that extracurricular educational activities, which are considered as one of the coping mechanisms, can have a good effect on mental and physical health and reduce stress and burnout.In order to reduce job burnout and increase the quality of life, planning for extracurricular activities should be done in order to increase coping mechanisms for against stress and burnout in students.Managers of residency curricula should be sensitive to the need for the inclusion of training programs for teaching empathic strategies and emotional management for the professional development of medical residents.This will improve the mental health of residents and enhance the quality of medical services by reducing the rate of burnout.This research had a number of limitations.The main limitation was that it this study was conducted only in one university, which limits the generalizability of the results.Another limitation is that data collection was done through convenience sampling, a method that can lead to biases in data collection and sampling.Therefore, caution should be exercised when interpreting the results, paying attention to the fact that the participants in the study were not selected randomly and were not from several universities.Additionally, we did not study other factors that may influence levels of empathy or burnout.These include personality traits, prior psychiatric disorders, or a history of using medication.Further studies should be conducted to determine other factors influencing empathic capacity during the physician's career.

Conclusion
To conclude, tThe findings of this study showed a negative association between empathy and burnout among medical residents, which suggests the need for adjustment of the existing burnout management practices at the institutional level.AmongOf all of the dimensionsubscales of empathy, standingwalking in the patient's shoes heldad the most important association with decreasingreduced burnout scores and was also a predicting variable for burnout.Medical educators must take these findings into account when planning innovative strategies to developpromote empathy among medical residents.Therefore, residents should be supported by managers to reduce burnout and improve empathic behavior.
The level of clinical empathy in the studied medical residents was relatively favorable, and their rate of burnout was below average.We found that there is a negative relationship between empathy and burnout and that empathy can predict the occurrence of burnout in medical residents.Therefore, it can be deduced that high levels of empathy can protect against burnout.When burnout is present, it may not allow for a fully empathic therapeutic relationship with patients.Hence, enhancing empathy skills through training programs can help residents protect themselves from burnout.Therefore, officials and planners of residency education should include the promotion of empathy in the residency curriculum in order to reduce burnout.Examining and understanding the complex links between empathy and burnout can help healthcare professionals reduce the risk of burnout.Future research to identify factors affecting empathy and burnout in residents can be used to design and implement appropriate interventions to reduce burnout in these individuals.

PONE-D-23-22729. Association between Burnout and Empathy in Medical Residents
It is with great pleasure that we resubmit to you a revised version of manuscript entitled "Association between Burnout and Empathy in Medical Residents".We would like to thank you for giving us the opportunity to revise and resubmit this manuscript.We appreciate the time and care you and the reviewers took in providing us with the valuable comments, and we have incorporated the suggested changes into the manuscript to the best of our ability.No doubt that these insightful comments have added to the theoretical and practical strength of this manuscript.We are ready to take more suggestions from you should you think the revised manuscript is still in need of further refinement.
According to the reviewer's comment, corrections were made in the final paragraph of the introduction section.
-The study design: it's known that the observational correlational studies include; cross sectional studies, case control studies, cohort studies.As your study is suitable to be crooss sectional study design, so I prefere to be more specific in mentioning the study design as cross section study.
In the manuscript, the study design was to cross-sectional.
-The method part need to be more oraganized as; study design, timing and setting, participant, sampling, tools of data collection, ethical consideration and data mangment and analysis.
The method section was organized according to the reviewer's comment.
-Please mention the response rate of the participants in the method section.
According to the reviewer recommendation, the response rate was transferred to the method section.
-Did you conduct a pilot study?No disclosure statement that describes the sources of funding for the work included in this submission.Review the submission guidelines for detailed requirements.View published research articles from PLOS ONE for specific examples.

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Table 3 : Predicting burnout through the level of empathy in residents
BurnoutAccording to Table

Table 43 : Predicting burnout through empathy sub-scalesdimensions in residents
According to the Reviewers' comment, Table3was deleted and its content was merged into Table4.Therefore, the title of this consolidated table was considered Table3.